Grief matters for children by Phil Ayres

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15/5/07

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Grief matters for children Support for children and young people in public care experiencing bereavement and loss At this point in time around 4 per cent of 5- to 16-year-olds in the UK have experienced the death of a parent, brother or sister. Many more have been bereaved of someone else close to them: a grandparent, friend or teacher. The death of a significant person has the potential to turn life upside down, evoking powerful feelings and often leading to further changes. With support and care, children and young people can develop resilience and manage the impact of a death on their lives. However, some children and young people struggle to cope. Research suggests that the death of someone important may have particularly harmful implications for the lives of children who are already disadvantaged, or who have experienced multiple losses (Ribbens McCarthy, 2005). Children and young people who are looked after by the local authority have all experienced significant loss by coming into the care system and being separated from their birth family. This report explores the impact of bereavement on looked after childrenâ&#x20AC;&#x2122;s lives, against the backdrop of the other losses they face. It looks at how their own prior experiences, and the care system itself, affect their experiences of bereavement and their accessing of support. It reports on exploratory consultations and pilot work with children, young people, their carers and the teams around them, and makes recommendations for further work. Funded by the Diana, Princess of Wales Memorial Fund, this report has drawn on the resources and partnerships of the Childhood Bereavement Network and the Healthy Care Programme, both based at the National Childrenâ&#x20AC;&#x2122;s Bureau.

Grief matters for children Support for children and young people in public care experiencing bereavement and loss National Childrenâ&#x20AC;&#x2122;s Bureau 8 Wakley Street London EC1V 7QE

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ISBN 978-1-905818-18-1

9 781905 818181

Grief matters for children Support for children and young people in public care experiencing bereavement and loss

Alison Penny

NCB promotes the voices, interests and well-being of all children and young people across every aspect of their lives. Published by the National Children’s Bureau. Registered Charity Number 258825. 8 Wakley Street, London EC1V 7QE. Tel: 020 7843 6000 © National Children’s Bureau, 2007 978-1-905818-18-1

Grief matters for children: Support for children in public care experiencing bereavement and loss

Contents Acknowledgements ..............................................................................................4 Introduction ...........................................................................................................5 Childhood Bereavement Network..........................................................................................................6 Healthy Care Programme ......................................................................................................................6 Information and data collection .................................................................................................... 6 Literature review......................................................................................................................................6 Questionnaires for carers and practitioners .......................................................................................... 7 Focus groups at Childhood Bereavement Network regional meetings................................................ 7 Consultation activities with young people ............................................................................................. 7 Gloucestershire Healthy Care Partnership........................................................................................8 Jigsaw4u and Surrey Healthy Care Partnership ...............................................................................9 Aldine House Secure Children’s Centre ............................................................................................9 Terminology.................................................................................................................................. 10

Experiences of bereavement and loss ................................................................. 11 Separation through death ............................................................................................................ 12 How common is separation through death among looked after children and young people? ... 13 Death as a contributory factor for entry into care................................................................................ 14 Mortality rates among family and friends ........................................................................................... 14 Other bereavements............................................................................................................................. 14

The impact of bereavement ................................................................................ 16 Grief as a personal response ....................................................................................................... 17

Mediators of bereavement ................................................................................. 18 Unexpected death ........................................................................................................................ 19 Traumatic death ........................................................................................................................... 19 Relationships before the death .................................................................................................... 19 Availability of support after the death ......................................................................................... 20 Adult anxieties ......................................................................................................................................23 Lack of information about the death and the person who has died..................................................25 Separation from the birth family...........................................................................................................26 Placement instability .............................................................................................................................28 Personal responses to other losses .....................................................................................................29

Support for carers .............................................................................................. 33 Training ....................................................................................................................................... 33 What should this training include?.......................................................................................................34

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What is the impact of training? ............................................................................................................35 Supervision, support and information ......................................................................................... 36 Books, helplines and other resources ..........................................................................................37 The wider social system ...............................................................................................................37 Specialist support ........................................................................................................................ 38 Child and adolescent mental health services (CAMHS) ......................................................................39 Specialist childhood bereavement services.........................................................................................39 Planning ....................................................................................................................................... 41 Care plans............................................................................................................................................. 41 Health plans..........................................................................................................................................42

Unaccompanied asylum seeking young people ............................................... 43 Traumatic experiences .........................................................................................................................43 Dealing with the here and now............................................................................................................44 Lack of information ...............................................................................................................................44 Cultural understandings of death and bereavement..........................................................................44 Accessing specialist services................................................................................................................45 Support for carers .................................................................................................................................45

Children and young people in secure accommodation..................................... 46 Involvement and inclusion after a death .............................................................................................47 Boundaries and isolation......................................................................................................................48 Behaviour and placement stability.......................................................................................................48

Conclusion.......................................................................................................... 50 Recommendations .............................................................................................. 51 Policy ............................................................................................................................................ 51 Partnership ................................................................................................................................... 51 Participation ................................................................................................................................ 52 Practice ........................................................................................................................................ 52

References ......................................................................................................... 53

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ÂŠ National Childrenâ&#x20AC;&#x2122;s Bureau 2007

Grief matters for children: Support for children in public care experiencing bereavement and loss

Acknowledgements Thank you to all the children and young people, carers, social workers, looked after children’ nurses, managers and others who gave their time to tell us about the impact of bereavement and loss and the support that is needed. Many people were involved in facilitating the consultations with children and young people: Chris Sands and Nikki Cox of Gloucestershire Healthy Care Partnership and Y-Plan, Zoë Channing and Sarah Everitt of Gloss Arts Education Agency, Rick Goldsmith of Catcher Media, Brendan McIntyre and Brett Riches of Winston’s Wish, Anne Davies and her team at Jigsaw4u, Liz Woolford at Surrey Healthy Care Partnership, Jon Banwell and Debbie Dawson at Aldine House and Shirley Payne of the Gone Forever Bereavement Trust. The advisory group gave helpful advice on the content of the questionnaire and the report. They are Anna Rickards of Essex CAMHS, Sophie Hughes of Herefordshire Healthy Care Partnership, Hazel Halle of the Fostering Network, Brigid Robinson of Voice, Mary Graham of the Atkinson Unit, David Holmes of the British Association for Adoption and Fostering, Kate Dornan of the South Eastern Health and Social Care Trust, Di Hart, Jonathan Stanley and Sheree Kane of the National Children’s Bureau. Helen Chambers of the Healthy Care Programme has offered inspiration and support for this work throughout its development, and Gill Frances has given valuable suggestions and direction. Steve Howell wrote the literature review, and the Childhood Bereavement Network Consultant Panel have supported the project as a whole. Lastly, thanks to the Diana, Princess of Wales Memorial Fund for seeing the need to explore the bereavement support needs of children and young people in public care, and giving us the means to do this work.

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Introduction A poem written by a young woman introduces this report on the support needs of children and young people in public care who have experienced the death of someone important, alongside other losses in their lives. My family said they would care for me My brothers said they would protect me My mother and father said they would never leave me And I never met my sister. My family left me My brothers are a danger to themselves and others around My mother and father died on me And my sister died too. My foster carers love me, they protect me And care for me. They will never leave me And I’ll never leave them, like my family left me I’m not abandoned anymore: I’m happy and smiling now I’m not crying I’m smiling.

Chantelle (Healthy Care, 2006) At this point in time, around 4 per cent of 5- to 16-year-olds in the UK have experienced the death of a parent, brother or sister (Green, 2004; ONS, 2005). Many more have been bereaved of someone else close to them: a grandparent, friend or teacher. The death of a significant person has the potential to turn life upside down, evoking powerful feelings and often leading to further changes. With support and care, children and young people can develop resilience and manage the impact of a death on their lives. However, some children and young people struggle to cope. Research suggests that the death of someone important may have particularly harmful implications for the lives of children who are already disadvantaged, or who have experienced multiple losses (Ribbens McCarthy, 2005). Children and young people who are looked after by the local authority have all experienced significant loss by coming into the care system: separation from their birth family. Many have faced particular losses that have a major impact on their lives: the ongoing lack of care in situations of neglect, the loss of trust as a result of an abusive relationship. Some of them will also have faced the death of someone important to them, either before they came into care, or while they were there. How do they make sense of this experience and find the support they need? This report explores the impact of bereavement on looked after children’s lives, against the backdrop of the other losses they face. It looks how their own prior experiences, and the care system itself, affect their experiences of bereavement and www.ncb.org.uk

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their accessing of support. It reports on exploratory consultations and pilot work with children, young people, their carers and the teams around them and makes recommendations for further development. Funded by the Diana, Princess of Wales Memorial Fund, this report has drawn on the resources and partnerships of the Childhood Bereavement Network and Healthy Care Programme, both based at the National Children’s Bureau.

Childhood Bereavement Network The Childhood Bereavement Network (CBN) is a national, multi-professional network of organisations and individuals working in the field of childhood bereavement. CBN promotes the interests of bereaved children, young people and their families and encourages the development of quality support for them. CBN’s Grief Matters for Children campaign, funded by The Diana, Princess of Wales Memorial Fund, calls for appropriate information and support to be available to all bereaved children, young people and their families, wherever they live and however they have been bereaved. For more information, visit www.childhoodbereavementnetwork.org.uk

Healthy Care Programme The Healthy Care Programme is an overarching programme which promotes the health and well-being of looked after children and young people. It provides a multiagency framework to improved health and well-being of looked after children and addresses the issues that affect their health outcomes. Better outcomes depend on the integration of universal services to address the needs of the child and family. The Healthy Care Programme promotes local Healthy Care services across agencies, and makes the five outcomes of Every Child Matters (HM Treasury, 2003) the driving force for the development and delivery of services to looked after children. Children’s participation is a cornerstone of the Healthy Care Programme. For more information, visit www.ncb.org.uk/healthycare

Information and data collection This report contains information gathered from small scale, exploratory data collection, consultation and piloting activities. It provides a snapshot of the experiences of the children, young people and practitioners who took part, rather than a comprehensive overview of the experiences generally of looked after children and young people.

Literature review A literature review was undertaken, looking at key theories and models of separation, loss, grieving and bereavement (and the closely related ones of www.ncb.org.uk

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attachment and attachment disorders in-so-far as how these related to and affect the child’s experience of grief and loss). It looked at the likely effects of loss or bereavement experiences on children in public care, and some of the actual or suggested interventions that can best meet their support needs and those of their carers.

Questionnaires for carers and practitioners Structured questionnaires were circulated among practitioners in England and Northern Ireland. A total of 91 questionnaires were returned from •

foster carers (28)

•

staff in non-secure residential childcare settings (4)

•

staff in local authority secure children’s homes (15)

•

independent fostering providers (28)

•

Healthy Care partnerships (5)

•

looked after children’s nurses (4)

•

specialist childhood bereavement services (including services in Scotland and Wales) (7).

Twenty two of the 28 foster carers were registered with a local authority, one was registered with an independent provider and five did not specify. Fifteen of the 19 responses received from residential settings came from secure children’s homes: this is an over-representation and further work is recommended to explore the relevance of our findings for children and young people in non-secure residential care. Quotes in this report taken from questionnaire responses do not refer to names, places or regions.

Focus groups at Childhood Bereavement Network regional meetings A series of eight regional meetings were held between March and May 2006. As part of a general discussion of the support needs of those caring for bereaved children and young people, the particular issues for foster carers were discussed. These meetings were attended by a total of 149 practitioners.

Consultation activities with young people A total of 58 children and young people were consulted through the activities of three pilot partner sites, and their ideas and experiences are presented throughout this report. The three sites, each involving a Healthy Care partnership and a local childhood bereavement organisation, were commissioned to consult children and young people in public care about their experiences and support needs relating to bereavement, and develop a small piece of work in response to their findings. There are many other examples of good practice in meeting the bereavement support needs of children and young people in public care, some of which will be presented in a forthcoming Healthy Care briefing for service managers and policy-makers. www.ncb.org.uk

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The consultations focused on the general population of bereaved children and young people, and on two discrete populations: children and young people in secure children’s homes, and asylum seeking young people. Where appropriate, the issues for these distinct populations have been raised separately in the report. Gloucestershire Healthy Care Partnership

Y-Plan, Young People Looked After Network in Gloucestershire, have been involved in a variety of creative activities with Gloss Arts Education Agency. Eight of the young people aged 12–15 worked with a film-making company, Catcher Media, to develop film-making skills. This medium was felt to be a creative and constructive way of consulting with children and young people on such sensitive topics as bereavement and loss. The brief was to produce a film which expressed ideas about how children and young people can feel and how carers can support them following experiences of bereavement and loss, and which would be used to promote discussion among foster carers, residential workers and social workers. The group was supported by Winston’s Wish, their local children’s grief support service. The project was explained to Y-Plan members and their carers, and eight members of the group volunteered to take part. They and their social workers gave consent to their participation. Activities for a preliminary workshop were planned by the film-makers with the help of the group’s coordinator. At the session, young people took part in a range of activities to contribute to the content of the film including developing a poem about loss, creating boxes which represented their feelings about the loss of someone or something precious, and giving ideas for a drama. They also began to explore filmmaking techniques and considered how to present themselves on camera. The group’s coordinator followed up with the young people after the workshop and checked whether they wanted to continue to participate. Filming took place over two days. The young people were given a choice about appearing in an interview on their own or with another member of the group. A staff member from Winston’s Wish attended to offer support on the first day and to make the young people aware of the service should they want to access it in the future. Again, the group coordinator followed up with the young people following their activity. The film was edited and shown to the young people for their approval and they evaluated their involvement. The learning, which they identified, had included how to put a film together and how to work in a group. Reasons why they thought the work was important to do included ‘because it may mean something to some people’ and ‘because it makes everybody aware of bereavement’. Suggestions for who should see the film included adults and other group members. Hopes for what might change as a result of people seeing the film included ‘children who have to be in charge and are neglected’ and ‘the awareness of bereavement’.

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Y-Plan will be collaborating with Gloss Arts Education Agency on a variety of further creative arts activities including a film about bullying and a series of workshops on street dance. Jigsaw4u and Surrey Healthy Care Partnership

Jigsaw4u is a child-centred charity working with children and young people affected by loss and trauma. Staff met with Surrey Healthy Care Partnership to discuss ways of addressing the bereavement and loss support needs of looked after children, young people and their carers. Analysis of the views of children and young people looked after by Surrey indicated that they wanted carers and workers to be more able to help them record and process memories of important people in their lives. Jigsaw4u consulted with 42 children and young people looked after by London boroughs about their experiences of bereavement and loss, and interviews with two social workers and foster carers covered the accounts of a further eight children and young people. This material informed the development of a training session delivered to foster carers in a London borough and which will be delivered to social workers in Surrey. Four staff members facilitated the consultations. Two were male of African origin: female staff members were Asian and white British in origin. Collectively, the team was fluent in 10 languages. All are active service providers in the social care field, and have experience of consulting with children and young people. Interviews were conducted at a variety of settings chosen by the young people. As an incentive, participants received a £15 voucher of their choice. Thirty-one of the children and young people interviewed were unaccompanied asylum seekers. All but two were living in a variety of supported lodging schemes. Of the other 19 children and young people, 16 were in foster care, one was in a residential school, one was in a medium secure psychiatric unit and one was in a psychiatric unit. Aldine House Secure Children’s Centre

Aldine House Secure Children’s Centre is a modern, safe and secure 8-bedded unit catering for eight boys and girls aged between 10 and 17. In 2006, Aldine House led the national development of the National Children’s Bureau’s training package Improving the Emotional Health and Well-being of Young People in Secure Care (Bird and Gerlach, 2005) and was part of the National Centre for Excellence in Residential Child Care (NCERCC) project for the implementation of the Healthy Care programme. The centre was commissioned to consult with children and young people about their experiences of bereavement and loss, and with staff about their support and training needs, and develop a piece of work in response to these identified needs. Staff from the centre accessed support and supervision from the local Gone Forever Bereavement Trust, and visited the Atkinson Unit in Devon to learn from pioneering work undertaken there which involved developing guidelines and a policy for addressing bereavement and loss, supporting all staff in developing their listening

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skills and training selected staff to provide specialist one-to-one bereavement support. In organising the consultations, an introductory briefing session was held for all the young people to give them a general understanding of what to expect and to give them the choice of whether to participate. All eight young people consented to participate, and attended an evening session in pairs, facilitated by one member of staff in the relaxed environment of the recreation room. The session included: •

compiling a mutual agreement together

•

top to toe relaxation exercise

•

explanation of outline of work/report and questions

•

consultation on experiences of loss and bereavement

•

decorating plant pot and planting seed.

After the sessions, the whole group met together to reflect and give any additional feedback. The young people were presented with a surprise gift of a hug bear as a thank you for their participation. Staff at the unit are currently developing a staff awareness training package in response to the needs identified in the consultation, with the help of Gone Forever Bereavement Trust.

Terminology Loss is the state of being deprived of someone or something which is valued (Howarth and Leaman, 2001 in Rowling, 2003).

Bereavement is the experience of those left behind after someone has died. Grief is the expression of an individual’s response to loss (Howarth and Leaman, 2001 in Rowling, 2003).

Child/ren and/or young people here refers to those under 18 years of age. A small number of young people over 18 were included in the consultations as they were able to reflect on their earlier experiences.

Carers here refers to foster carers and residential workers, those dealing with children and young people on a day-to-day basis.

Looked after children or children and young people who are looked after refers to children and young people in public care.

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Experiences of bereavement and loss For most people love is the most profound source of pleasure in our lives, while the loss of those whom we love is the most profound source of pain. (Parkes, 2006, p.1) Separation from the people we love, whether through death, illness, legal process or other circumstances, is one of the most significant and distressing events we can live through. It is normal to respond powerfully to an experience of this magnitude, yet the feelings evoked by this grief response can be overwhelming and frightening. Young people in public care experience a variety of separations and losses in their lives. All have been separated from their birth family through coming into the care system. Young people at Y-Plan were eloquent about the way their grief at these separations made them feel: Loss Losing Lost Privacy. Loss Losing Lost Contact. No letter No phone call No touch Losing touch. A ghost walks through you, a distant relative far down a path overgrown with the things that have happened. A thousand daggers twist in my guts, the hurt like spiders crawling up my throat, worry wriggles under my skin. My legs are stiff as steel, My arms are stiff as trees. My eyes puff up like bags of crisps ready to be popped Stomach an erupting volcano Numb body full of ice, Mouth is clamped shut My head holds an electric storm Body frozen, everything stops and my eyes just stare. www.ncb.org.uk

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ÂŠ National Childrenâ&#x20AC;&#x2122;s Bureau 2007

Grief matters for children: Support for children in public care experiencing bereavement and loss

Losses which questionnaire respondents identified as being significant in looked after children’s lives included: •

separation from parents

•

separation from siblings

•

separation from the extended family

•

separation from friends

•

a drop or break in contact

•

loss of home

•

loss of school

•

loss of neighbourhood

•

loss of sports teams

•

loss of previous fostering or other placements

•

experience of leaving care.

Others have identified other significant losses such as pets (Holland and Randerson, 2005, p. 42) and point out the difficulty of knowing which losses will be particularly significant for an individual child or young person. One young person talked about how much he missed his room: My room was a lot bigger than the one I have at the moment and I used to love my room ’cos it had a beautiful view and I was decorating it myself as well. It was really nice. (Young man in foster care) There is no shared hierarchy of loss and for each individual the experience will depend on the degree of attachment and how the loss or losses are perceived by the young person. The losses of young people in care are rarely straightforward, are frequently complex and the better they are considered and understood, the better we can begin to help and support the young people. (Holland and Randerson, 2005, p. 53)

Separation through death For some children and young people in care, their experiences include the ultimate separation from someone important to them: separation through death. Jigsaw4u consulted young people looked after by the local authority on their experiences of bereavement, against the backdrop of other losses. A 15-year-old boy told us that when he was 10 his grandfather died. No one talked with him about what had happened but he was invited to the funeral. He said that he felt ‘gutted’ about the death of his grandfather as he had been the only person who had understood him and he felt unable to cope. A close friend of the family provided him with alcohol to assist with his pain. Still no one spoke to him about his grandfather and he spiralled into excessive drug and alcohol misuse. His anger accumulated and spilled out into violence. He talked about getting into fights that

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resulted in people having broken limbs and even a fractured skull. He was taken into care and still no one spoke with him about his grief. A 16-year-old girl has had six close friends die in the last few years. She wanted to talk about a friend whom she had seen early in the day before he returned home to his family to celebrate his brother’s birthday. While at home he had taken his own life. She felt total disbelief when she heard about what had happened and she kept calling him on his telephone. The funeral was painful as the floral tributes reflected his love of football and was full of young people. Throughout the local area his friends had left graffiti messages reading RIP. The mother of a girl aged 11 and a boy aged six died following cancer surgery. The girl had already been excluded from school and was placed in a boarding school two weeks after her mother’s death. The boarding school were offered grief support by an outside agency but continually postponed it, feeling that the time was not yet right for the intervention. Her brother and father attended grief support but growing evidence of neglect and sexual abuse predating her mother’s death resulted in her brother being taken into care. She feels her life would have continued to deteriorate if she hadn’t been able to access grief support for herself through advocacy. A social worker telephoned to talk about an 11-year-old girl whose mother had abandoned her when she was younger, after telling her daughter that she would collect her when she was ‘better’. She had always wanted to trace her mother and her social worker worked with her to try and discover her whereabouts. Initially the Salvation Army missing people’s department couldn’t help, but later discovered that she had died in a local hospital six months earlier, as a result of alcohol abuse. The friend with whom she had been living told them that she was cremated and her ashes had been scattered. The girl is left with a number of questions, these include: What happened to her mother in the last few years? Did her mother have any belongings, and where did they go? Did her mother ever think about her daughter, and did she really care about her?

How common is separation through death among looked after children and young people? There is little published statistical information on the proportion of looked after children in the United Kingdom bereaved of a parent or someone else important to them, either before, during or shortly after leaving care. This reflects a wider issue of the difficulty of accessing data on bereavements in the lives of children generally. Improved data collection is recommended to help plan policy and practice. However, a study of the care ‘careers’ of younger looked after children (under five years old) in Northern Ireland found that 30 per cent of the sample had experienced significant bereavements (Cousins and others 2003, p. 56). A recent study in Sweden found experience of parental or significant carer death to be relatively common among children in care in that country, and certainly more frequent than among the general population. At the age of 18, 11 per cent of former www.ncb.org.uk

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residents of long-term out of home care were bereaved of their mother, 11-13 per cent were bereaved of their father and 3–4per cent were orphaned, compared to 1 per cent, 3 per cent and 0.03 per cent respectively of their non-foster care peers. Twenty-six per cent were bereaved of at least one parent, compared to 4 per cent in the general population. By age 25 the figures had increased, with 36 per cent of the care sample having lost at least one parent, compared with only 7 per cent of the non-care population. (Franzen and Vinnerljung, 2006, p. 254). The main explanations which the study put forward for such comparatively high levels of bereavement – both as a contributory reason for entry into care and/or parental death from alcohol or drug-related causes – were supported by responses to our questionnaires in the UK.

Death as a contributory factor for entry into care Children and young people may come into care after a death because there are no surviving relatives to care for them. Data on the reason for children entering care does not reveal the numbers admitted for this reason: they would be included in the general category of ‘absent parenting’, which accounted for 8 per cent of admissions in 2005 (DfES, 2006c). Focus group participants gave examples of children being admitted into care following the death of a lone parent: even where such a death was expected, plans had not necessarily been made for the future care of the children. In other cases, a death will contribute indirectly to a child or young person coming into care. Surviving relatives may be unable to provide care, either as a result of existing mental health or other difficulties, or as a result of new pressures which emerge through their own overwhelming grief. A study by ChildLine (Cross, 2002) also revealed that some children became vulnerable to abuse following a bereavement in the family. Again, these complex trajectories are not revealed in the data on reasons for entry into care.

Mortality rates among family and friends Some questionnaire respondents felt that looked after children were more likely than the general population to experience bereavement (either before coming into care, or while they were there), because of environmental and family factors that increased the risk of mortality among their birth families and friends: Many children and young people who are looked after come into care due to parental drug or substance misuse, or domestic violence. They are at higher risk of family bereavement through death due to risk taking behaviours, poor general health, mental health problems, suicide and violent crime. (Looked after children’s nurse)

Other bereavements A respondent observed that it is not just the death of relatives perceived as being close that has the potential to affect children and young people:

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We have a number of children who are in care who have lost relatives, who may not have been very close to the child but which have never been addressed (Independent fostering provider) The roles which different people play in children and young people’s lives varied from family to family: grandparents had played a pivotal role in the lives and the well-being of several of the children and young people in public care consulted by Jigsaw4u, and their deaths were very significant. Respondents identified other experiences that they felt had been significant in the lives of some of the children and young people they were supporting: these included the death of a foster carer or a residential worker, and the termination of a pregnancy. A Y-Plan member described the importance of her relationship with a neighbour: When I was little I used to live with my mum … and we had a next door neighbour ... She was really close to me and she used to always look after me and stuff and she would treat me like I meant something … She used to always help me if I was upset or scared of my mum and her boyfriend fighting and stuff … and then when I went to foster care I did like write to her a few times and she always sent me a Christmas card. I didn’t know how to feel when I got told that she’d actually died because I hadn’t seen her in so long and that. I was just really annoyed with myself about why I didn’t stay in touch with her and that and I wish I had, because when someone dies or whatever I just think like, ‘I’ll never see that person again’ and that’s really upsetting. Like they might still be alive and you might never see them again but it makes you more upset knowing that you can’t ever see them again. As Ribbens McCarthy (2005) cautions ‘Whether or not a particular bereavement is felt to be significant in the life of a young person cannot be “read off” from the category of the relationship’ (p. 2).

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The impact of bereavement Bereavement is a profound experience that has the potential to affect children and young people’s lives in physical and practical as well as emotional ways. Its effects can be felt for many years, and in many aspects of life including health, feelings, behaviour and relationships. Children and young people interviewed by Jigsaw4u described how their experiences of bereavement affected them on a day-to-day basis. Headaches, aches and pains and difficulties sleeping were the most common physical reactions: less common symptoms included memory loss, back pain, eating problems and itchy skins. Invariably, these young people also experienced psychological pain about their past and day-to-day life. Young people told interviewers that they often can’t help but think constantly of the past and their family. At school or college, learning is more difficult as children and young people cannot concentrate on the ‘here and now’. The start and end of the day were mentioned as particularly difficult times, when most of the young people are alone with their thoughts. Many said they feel alone and different, and most find themselves prone to bursts of anger, which was also discussed by Y-Plan members in response to losses generally: You can feel really, really upset and you feel really angry like you want to smash something up. I start getting really sarcastic and cocky and that. I would start hitting things as well. When I was at my old house we had a plaster wall and I accidentally put my fist through it. One girl explained that anger could hide other feelings: If you’re angry because you’re sad, they wouldn’t know that you’re sad, and then you wouldn’t have to talk about it or anything, so it would just be easier. The responses described by the children and young people were also reported by our questionnaire respondents. The behaviours which they had observed following a bereavement among the children and young people in their care included aggression, being withdrawn, self-harming, suicide, developing an eating disorder, urinating, vomiting, clinginess, poor memory and in some cases symptoms of posttraumatic stress disorder. Some of these behaviours were very distressing to observe: This is particularly poignant when a young person has lost a parent through drug overdose. Frequently, a young person will emulate the behaviour, often putting himself or herself at risk of significant harm. (Local authority secure children’s home staff member)

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Reactions to bereavement identified as common among the general population of bereaved children (not specifically the looked after population) include: •

sleep disturbances, insomnia, nightmares

•

eating disorders, loss of appetite

•

toilet problems – may regress to soiling or wetting as when younger

•

new physical disorders, or exacerbation of existing ones such as asthma, eczema

•

anxiety, separation anxiety, mood swings, withdrawal, aggressive behaviours, school phobia

•

poor concentration

•

possible guilt problems – thinking they are responsible for the loss

•

loss of memory, learning difficulties

•

hyperactivity, acting out, taking risks.

(Chan and McConigley in Cousins and others, 2003, p. 63)

Grief as a personal response However, grief in response to death is a personal reaction to the loss of a particular person. Each child or young person’s personality and experience is unique to themselves and following a bereavement ‘each young person will respond in his or her individual way’ (Local authority secure children’s home staff member). Another secure children’s home staff member described how young people in the unit had reacted differently to the death of a staff member: one had felt responsible and their behaviour deteriorated as a result, whereas the others felt determined to succeed and their behaviour improved. This demonstrates how the meaning which a particular death has for an individual child or young person is highly significant in influencing how they will respond to it, as Rutter has written of key events generally: It has been crucially important to appreciate that the risk derives as much from the meaning attributed to the event as from objective qualities of the event itself (2000, p. 390 in Ribbens McCarthy, 2005, p. 36).

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Mediators of bereavement Increasingly, studies into the effects of bereavement on children and young people’s lives have taken account of factors which may mediate and moderate their experience (for example, Worden, 1996, Dowdney, 2000). Models that acknowledge these factors are more able to account for ‘opposite effects’ (Ribbens McCarthy, 2005) among young people’s responses, such as those shown by the young people in the secure home mentioned above. They are more likely to offer more helpful conclusions about whether bereavement is a risk factor for poor outcomes both in childhood and in later life, such as depression, early sexual activity, drug use, offending behaviour and educational attainment (Dowdney, 2000, Ribbens McCarthy, 2005). These influential factors include characteristics of the bereaved person (including their age, gender and coping style), their family (including the relationships both before and after the death, the changes which the family undergoes and the mental health of surviving relatives) and their wider social contexts (such as cultural aspects affecting rituals around the death and the availability of support) (Ribbens McCarthy, 2005). Factors around the death itself will also affect the grief response: for example, whether it was a traumatic death, whether it was expected or not, and whether the young person feels any involvement or responsibility for the death (Worden, 1996; Stokes, 2003) Surveying studies of bereavement among young people that consider these mediating factors, Jane Ribbens McCarthy concludes that: For some young people … bereavement may be compounded by other disadvantages or multiple difficult life events, and this may clearly indicate an increased risk of negative outcomes. Furthermore, bereavement and multiple losses are much more likely to be experienced by young people who are already disadvantaged, but these young people are less likely to have organised support available to them. (2005, p. 64) As shown, children in public care, by the very fact of being in care and their reasons for being there, and the associated prior experiences, are more likely to experience bereavement and other losses of various kinds than their non-care peers. Questionnaire respondents felt that the losses experienced by children and young people in care could combine with a bereavement to a particularly acute effect: Losses though death add to the continued significant losses of family, school, peers and childhood that are a factor for all looked after children. (Looked after children’s nurse) The following section looks at some of the features of life in public care that can mediate some children and young people’s experiences of bereavement and may increase their risk of poor outcomes. Yet, as a young person warned us, it is

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important to avoid over-generalisations and to remember the personal and particular: Everyone’s got their own feelings and if you’re in a foster home it don’t really make any difference [to that]. (Young person in foster care)

Unexpected death Deaths where there is some warning and time to prepare have been seen as easier to grieve than those which are sudden and unexpected (for example, Parkes, 1972 in Worden, 1996) although this may be balanced by other supportive factors in the family (Worden, 1996). Even when a death has been expected, adults within a family may not have shared the information with the children and so they will not anticipate the death (Stokes, 2004). Difficulties with contact and hearing important news from family members can exacerbate this problem for some children and young people in public care.

Traumatic death As already noted, a number of our questionnaire respondents identified that some children and young people who were looked after were at increased risk of sudden and traumatic deaths from suicide, accident or overdose in their birth families. Within the Trust there are areas of high unemployment and deprivation. Within these areas and across the Trust, suicide rates are especially high amongst young men. (Looked after children’s nurse) Following a traumatic bereavement such as witnessing an accident, or the murder of one parent by another, children and young people may develop a variety of stress reactions which may inhibit the normal processes of grieving (Yule, 2005). These can include intrusive thoughts about what has happened, flashbacks, separation difficulties, problems concentrating, difficulties in talking with parents and friends, and heightened fears and anxiety about safety. Studies suggest that children who are bereaved through the murder or suicide of a parent are at greater risk of depression and of post-traumatic stress disorder (Dowdney, 2000).

Relationships before the death Jealousy, anger and other negative feelings towards the person who has died can affect children’s grief. Sadness at the death may be mixed with relief and this can lead to feelings of shame and self-reproach (Dyregrov, 1991). Respondents discussed the ambivalent feelings which some looked after children have towards members of their birth families, including jealousy of siblings who

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remained in the birth family and guilt towards parents who had been judged unable to care for them: They love their parents and often feel guilty that they feel more comfortable with the carers. (Foster carer) Separation from siblings can lead to feelings of anger and betrayal – why am I here and he/she isn’t? (Independent fostering provider) Children who have been abused by members of their birth family may have ambivalent feelings of both anger and loyalty to the person who has harmed them: memories of positive experiences of care may be retained differently from memories of abuse (Cloitre and others 1996 in Stokes, 2003). Jane Ribbens McCarthy suggests that for some children and young people, the death of a parent could bring benefits if the relationship was abusive or conflict ridden (2005, p. 34). However, Dowdney (2000) notes that bereaved children from families with a prior history of parental conflict and separation seem to have a higher risk of emotional and behavioural disturbance following bereavement. When these or other ambivalent relationships are ruptured by death, a child’s response can be understandably complicated. It is not just the children and young people who may feel ambivalent towards the birth family. Carers may have strong feelings towards those who have previously neglected or harmed the children in their care, which could bring challenges in accepting children’s grief for even apparently ‘undeserving’ or abusive figures. In some cases, children may think their carers have these feelings: I have found that the children often transfer their feelings and become mind readers saying that ‘I know you think my family are disgusting’ and as a result we work especially hard to build honest relationships with birth families in order to support the child. (Foster carer)

Availability of support after the death One of the key mediators of children’s experience of bereavement is the availability of supportive relationships and care following the death of someone significant to them (Ribbens McCarthy, 2005). Worden found that after the death of a parent, the most powerful predictor of the child’s adjustment to the death was the functioning of the surviving parent, and their capacity to care for the child (Worden, 1996). Based on his study of 125 children bereaved of a parent, Worden suggested that following a bereavement, components of support that most children will need are: •

adequate information about a death and what has happened

•

addressing of their fears and anxieties about who will care for them, and about the safety of their surviving relatives

•

reassurance that they are not to blame for a death

•

people to listen carefully to their fears and questions

•

their individual feelings to be acknowledged and respected as valid

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•

help with overwhelming feelings which might emerge in behaviour

•

involvement and inclusion in the rituals and discussions around a death

•

continued routine activities

•

modelled grief behaviours – to see other people grieving

•

opportunities to remember the person who has died, both after the death and as they go through life.

Among the children and young people Worden studied, these needs would be met by surviving relatives and their networks of support. The family context is significant for the life of any bereaved child (Dent, 2005). For bereaved children and young people in public care, it is foster carers or residential workers who meet their day-today emotional and practical needs, supported by a multi-agency team acting as the corporate parent. Encouragingly, we heard many good examples from questionnaire respondents of how carers were able to promote communication, cohesion and stability and meet the needs of the bereaved children and young people in their care. Eighty-six per cent of the foster carers and residential staff who had recent experience of caring for a bereaved child or young person were able to describe supportive techniques and strategies they had used. The most frequently mentioned was simply listening, being there and talking. Young people at Aldine House said that having someone to listen when they are ready and able to talk was helpful in dealing with bereavement and loss, as was learning to trust, and staff who understood their individual situation. Worden identified that bereaved children and young people need someone who will listen properly to them, give them time to talk and answer difficult questions honestly. The listener can be someone other than a parent, and research on divorce has highlighted that support can be offered to young people through strong relationships with another adult or friend (Amato, 1993 and Hetherington, 2003 in Ribbens McCarthy, 2005). Some carers described the things they had done in the immediate aftermath of a death, such as supporting the child in going to the funeral and in some cases to participate in the planning. Having an opportunity to say goodbye was seen as important by the young people at Aldine House. Foster carers responding to our questionnaire discussed how they had facilitated this for the children in their care: Helped the child write to Social Services to ensure her father’s wishes were carried out … funeral director allowed the young person to visit her father in the chapel of rest as and when she wanted. Priest carried out a unique service at the graveside according to the wishes of the child. (Foster carer) This young man had a suit for the funeral, a photo was taken with his choice of gift to leave in the coffin with his father. (Foster carer) Others described ways they had helped the child or young person retain memories of the person who had died, even if they didn’t know the person themselves. These strategies included keeping photographs of the person that had died and the family. www.ncb.org.uk

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This could also form part of life story work, which several carers mentioned. Memory boxes had been used as a place to store letters and other precious and significant things. Several respondents mentioned visiting the grave with a child or young person, sometimes to commemorate an anniversary. One had helped young people to release balloons with messages attached on the anniversary of a death. Other dates such as birthdays and Mothers’ Day were remembered. One response highlighted how it was helpful for staff to be aware of key dates and the possibility that they might trigger memories that would impact on the child or young person: Anniversary of young man’s father’s death occurred during [his] stay. He opted not to acknowledge the day but staff [were] aware of possible need for further support. (Local authority secure children’s home staff member) One carer mentioned using the Winston’s Wish website to record memories and name a star after the person who had died. This carer also tried to include memories in everyday family life: Often referring to the parent who has died (for example, ‘Your dad often did poached eggs’). (Foster carer) Some carers had helped children and young people to create memory gardens, including a residential unit that had established one around a bench dedicated to parents who had died. One residential worker from a larger unit cautioned that memory gardens were less favoured as a support strategy as they were ‘prone to damage by third parties’ which could cause obvious distress to the child who had created it. Carers also mentioned helping bereaved children to keep in contact with important members of their birth family, but acknowledged that this needed careful handling, as with any child or young person in public care. [There are] many complex issues, for example, Is contact regular? Is it supervised? Where is it? How well can foster carers support children before and after contact to enable the child to go and not feel conflict of interest or loyalties. (Independent fostering provider) One young woman in care described how difficult it can be to manage contacts and phone numbers: When you’re really little it’s really hard to like be organised and keep all those numbers ’cos you’re not used to it. Clearly, many carers are able to provide sensitive care to promote the well-being of children and young people experiencing bereavement, helping them make sense of what has happened, rebuild their lives in the absence of the person who has died, and develop resilience which will help them cope with future losses.

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However, not all bereaved children and young people in public care receive this level of support. Some of the young people consulted by Jigsaw4u described how they lacked opportunities to discuss what had happened. One boy who was living with foster carers at the time of his grandmother’s death said that no-one had told him about his Nan until two days before the funeral. No-one had spoken to him about her and he has become increasingly angry. In the absence of adequate support, the young people used other techniques to understand their situation and muster sufficient drive to get through each day. Thirteen per cent of the children and young people try to ‘forget’ their experiences. Some described using alcohol, drugs and violence as a way of avoiding their pain. A 17-year-old girl who has been in psychiatric hospital wrote: I was 10 when my mum died – we knew that she was ill with cancer but she had surgery and went to intensive care afterwards. Not being able to help her pain was torture. After she died I was so upset. All I wanted was someone to talk to but instead they punished me by sending me away. I was in care – why would no one talk with me … why didn’t anyone understand? In the end I suppressed my feelings, because I hadn’t been told how to deal with my feelings. They still came through though, but in wrong ways. I would be rude to people, have fights and get into trouble all the time. I was angry and misunderstood. I got bullied so I bullied other people. I never got help because I was in the unit. Adult anxieties about death and bereavement can compromise the support available to any child. For children and young people in public care, accessing support may also be hindered by structural factors in the care system and their experiences of prior and concurrent losses.

Adult anxieties Bereavement is an emotional subject and can be difficult to approach both for children and their adult carers. The latter may have their own painful experiences or fears of loss and bereavement, or may simply feel inadequate and worried that they will make things worse by approaching the topic. Adults may believe that not talking about death somehow protects children from its effects, or helps them to put the painful event behind them. My kids lost their mother at a very early age, due to sudden death … this is not something I feel they have dealt with. It is not a subject that they openly speak about and not one that their workers or family chose to have with them. (Foster carer) Some foster carers avoid discussing it/are fearful of broaching it. (Independent fostering provider) Children are given permission to grieve by seeing others around them expressing their sadness. Even when carers as well as the child are experiencing grief, for example, for a partner, for another child in the placement, or for a staff member, they may try to shield the child from seeing this. www.ncb.org.uk

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Adults sometimes think that children should not be exposed to their grief. (Independent fostering provider) Adults may have strong ideas about how children do or should grieve, perhaps based on their own prior experiences, or on a simplified knowledge of grief theory without an accompanying acknowledgement of individual differences (Melvin and Lukeman, 2000). Two years after the death of their parent, a quarter of the children in Worden’s study were being told to show more feeling, while another quarter were told to finish grieving (Worden, 1996, p. 143). Children’s age, culture and characteristics including their coping and communication style will all affect how their grief is expressed. Some children and young people are more open than others in discussing their feelings and experiences, and these differences can cause anxieties to carers, particularly if they did not know the child well before the bereavement. Young people from Y-Plan were clear that keenness to talk varied between people and at different times: I get more upset if people pesterise me. They keep coming up to me and go ‘Oh are you alright?’ They keep saying that. Sometimes you want to talk about it and sometimes you don’t. [Some people] don’t want to talk about like if some of their family have died. That’s like their own right so people should respect it. Careful listening involves being ready to talk when the child or young person wants to, rather than pressing them to do so. A foster carer described how this respect and flexibility could be maintained with a continued offer of support: I would always welcome support for my kids but the timing has to be right for them. I attempted to do some life story work with them but they did not wish to continue with this. (Foster carer) Cultural differences may affect how young people express their grief and adults may be uncertain about particular practices and understandings: We need more awareness of the impact of loss in other cultures. (Local authority secure children’s home staff member) Questionnaire respondents identified that adults may need specialist communication methods and tools in supporting bereaved disabled children and young people in public care. One bereavement care provider felt that these children’s needs could be overlooked and that there was a ‘practical problem in that bereavement support was not offered readily/at all to children in special schools’ (Bereavement care provider). Further work is recommended to explore these needs.

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Lack of information about the dea th and the person who has died Lack of information about children’s experiences and prior circumstances can hamper carers’ attempts to offer support. Some children and young people may have experienced bereavements about which their adult carers know nothing. A full history would be very helpful – we are often working in the dark with no knowledge of past history and without intervention from a manager we are not allowed to see the files due to confidentiality. The people entrusted with 24 hour care of the children are often the only professionals without all the facts. (Foster carer) If it is known that a young person is bereaved, helping them to come to terms with this is given priority in a care plan. Unfortunately, within referrals this is often not acknowledged. (Local authority secure children’s home staff member) Sometimes carers will know about a death in a young person’s history, but will not be in full possession of facts about the circumstances. This makes it difficult for them to provide adequate information about what has happened or what is going to happen: information that can help reassure children and young people’s fears about the causes of illness or death (Worden, 1996). Without sufficient information, children and young people may be worried that their feelings, actions or words have contributed to a death, especially if they are at a stage of development in which they feel they have magical powers over the world, or if they had ambivalent feelings towards the person who has died (Worden, 1996) and this can lead to feelings of guilt and self-reproach (Dyregrov, 1991). A child’s need for clear explanation and understanding around the time of death and events afterwards is not felt to be any different even if they do not live with their natural parents. (Bereavement care provider) Focus group participants said how difficult it can be for carers who have to break news of a death in the birth family to a child in their care, especially when they are not able to explain the full circumstances. Life story work was discussed by respondents as a way of helping the child or young person to identify the gaps in their knowledge, and to begin to piece together information which might be helpful to them. A child I have [who experienced a bereavement] and shortly afterwards was taken into care was left with feelings of guilt through lack of understanding of the circumstances leading to the death … Life story brought the issues to the forefront. This was followed with simple rituals such as visiting the grave a couple of times a year to tidy and plant flowers. This has gradually led towards the ability to talk about the dead person and the incident itself. (Foster carer) It is increasingly understood that an important part of grief is to find ways of remembering the person who has died, and forming a ‘continuing bond’ with them, which is compatible with other, new and continuing relationships (Klass and others,

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1996). Connections that are maintained through people or objects, and opportunities to talk about and remember the dead family member in a way which is meaningful, can be comforting to children (Stokes, 2004). Yet providing these opportunities can be difficult for carers who did not know the person who has died, or who are concerned that some of the memories held by children or young people will be painful or traumatic, particularly if the relationship was abusive or neglectful.

Separation from the birth family Being involved with discussions and rituals can help children to feel involved and included in the family’s response to a death (Worden, 1996). Choices about whether to attend the funeral, adequate preparation if they decide to go, and opportunities to contribute to the planning have been welcomed by children and young people. Adults who were not given the choice about attending a funeral when they were bereaved as a child may express regret about this (Holland, 2001). Worden suggests that children learn how to mourn the death of someone important to them in the same way as they learn many things: by seeing other people doing it. He argues that children need adults who can ‘model appropriate grieving’ and who can discuss memories both good and bad, who can reflect on what they will and won’t miss about the person who has died. As well as showing children how to cope with a death, these activities can promote a shared experience in the family. Being involved in these ways is often more difficult for children and young people who are separated from their birth family. They may be less able to prepare for an expected death than children living with or in close contact with the dying person. Sometimes children are unable to say goodbye and sorry to family members. (Independent fostering provider) This distance may mean the impact of a death is underestimated: The ‘impact’ on looked after children is not always taken seriously if the child or young person has not lived with the parent/relative for some time. The feelings of the child or young person are ‘dismissed’ by some professionals. This needs to change. (Independent fostering provider) Children and young people who are looked after may feel isolated from the rest of their grieving family. However sympathetic and understanding their carers, they are not grieving themselves and so there may be a lack of ‘shared grief and experience’ (Foster carer). Looked after children can often be left out of the ‘normal’ mourning process because they are living with a family that will not be affected by the loss of someone in their birth family. (Independent fostering provider) At least at home you’ve got like your family around you and it’s better cos at least you know that they’re there, but then if you’re in care with foster carers you’re like not with your family. (Young woman in care)

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Some respondents felt that it could be easier for carers than for a birth family to maintain emotional availability to children following bereavement, given that they were not overwhelmed by their own feelings of grief. Ribbens McCarthy (2005) shows that while some studies have found widow(er)s to be at increased risk of poor physical and mental health (Gersten and others, 1991; Parkes, 1998; Worden, 1996) which might compromise their parenting skills, Mack (2001) found that for young people, the death of a parent did not result in a poorer quality relationship with the surviving parent. Christ (2000) also showed how surviving parents could be available to support their children, while grieving themselves. Even though carers may not be grieving for the person who has died, supporting children and young people through their experiences of bereavement is difficult and demanding work that can remind carers of their own experiences of loss. This may be very prevalent: a survey at the Atkinson Unit secure children's home identified that all teaching staff had experienced the loss of someone they loved in the last five years (Fitzpatrick, P, 2005/6). The distress that children may show in their grief can leave carers feeling inadequate: If they carry on going on at you and like trying to make you feel better, maybe they’re trying to like make themselves feel better, to make them think like that they’re doing a good job of being a foster carer. (Young person in foster care) Many respondents identified the pain and disruption for children and young people in public care of being separated from their parents and siblings, in particular when they had been caring for them prior to becoming looked after by the local authority. I have been working with a 15-year-old girl placed 20 miles from home (the nearest placement that could be found. She had an excellent relationship with her carer … But she regularly ran away, the reason being that she missed her younger siblings and felt she couldn’t ‘look out’ for them when she was living so far away. (Looked after children’s nurse) Children placed with us often experience anxiety regarding the safety of separated siblings. This even occurs to a degree when siblings are also placed with another family within the agency. (Independent fostering provider) In some cases, fears about surviving relatives may be quite accurate, and while these anxieties can be acknowledged, they cannot be reassured. After the death of a sibling and the suicide of their father, a group of siblings were reported to: Feel very guilty about Mum, being in care. [They] feel they have to go to contact. If [they do not go, they are] worried Mum will kill herself too. (Foster carer) In some cases, this could be a reason for young people absconding from a placement following a death: They want to be with their families/loved ones at times of bereavement. (Looked after children’s nurse)

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However, a number of respondents felt that in some circumstances, a death in the birth family could strengthen a placement ‘because there is no internal conflict for the child that they may return to the family home’ (Looked after children’s nurse). [Bereavement] enabled one child to relax and become part of the foster family without the pull of the birth family and the sense of responsibility towards them. (Foster carer) Jane Ribbens McCarthy argues that ‘bereavement may not always be experienced as an unmitigated loss: rather, it is a change, and change always has the potential for gains as well as losses’ (2005, p. 1). Nevertheless, even where a bereavement is followed by an apparent strengthening of placement, the complex and contradictory feelings which children can experience must be acknowledged.

Placement instability Despite many initiatives to improve the stability and quality of placements, many children and young people experience instability in their lives in the care system (DfES, 2006d) and this can compromise the support available to them following a bereavement. Children who are moving from placement to placement face repeated disruptions in their routines. Worden (1996) looked at the influence on bereavement of the disruptions and changes in family life which happen as a result of a death, recognising that some of the difficulties which bereaved children experience do not show themselves immediately but may take up to two years to emerge. These changes might include shifting of domestic routines, chores and responsibilities, and moving house and school as a result of financial changes (Dowdney, 2000). Worden found that children who experienced many changes in the months after a death were more likely to have health problems and to be anxious. The longer these changes persisted, the greater their impact was on the children. The effect of this disruption is that children and young people can lose ‘potentially supportive ongoing relationships with professionals’ (Healthy Care partnership). It can be hard for carers to identify the impact of a death on a child who they do not know well, or whose bereavement happened some time ago. Looked after children’s [bereavement support] needs may be missed due to several moves sometimes in a short space of time. Records often take too long to catch up with the child and [in the] new placement bereavement can be seen as just another problem for the child and not seen as urgent or … [needing] specialist help or support. (Bereavement care provider) Difficult to assess how much impact death/loss have on our young people due to length of time most have spent in care/away from their families. (Residential worker) If a bereavement happens during a placement, it can still be difficult for carers to identify what is happening and how the child or young person is feeling.

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Difficult to quantify [how feelings and behaviour have been affected by bereavement. His] dad committed suicide, but [his] behaviour had been very erratic before his loss too. (Foster carer) Bereavement care providers indicated that institutional issues within residential placements such as shift patterns, rotas, holidays and staff turnover could compromise children’s ability to attach to an adult who will understand how it [bereavement] is for them [and to] access … places of comfort to grieve in a busy often noisy environment. (Bereavement care provider)

Personal responses to other losses Children’s responses to prior or concurrent losses in their lives were seen by respondents as a further key factor affecting the availability of support to them following the death of someone important. In some cases, previous experiences made it difficult for children and young people to develop healthy, trusting relationships with carers who could support them, particularly when their responses emerged in behaviour which was perceived as difficult. For many of our looked after children they simultaneously experience loss of parents and relatives, loss of siblings, loss of friends, loss of home and familiar surroundings, loss of their property including toys, possibly loss of a pet and loss of routine. (Healthy Care partnership) I think the biggest losses have been of the familiarity of their home lives … and the insecurity this causes is going to take time and patience until the foster home and its routines become familiar and reliable. (Foster carer) Many children and young people will be able to manage these changes and disruptions, particularly if their early attachment experiences have been secure. A baby or young child whose formative experiences include close, loving relationships with a main caregiver or attachment figure who is ‘attuned’ to his or her needs will be able to explore the world from a secure base, learning that (s)he will not be overwhelmed by strong feelings of anxiety and stress. This secure attachment will help the development of ‘mind-mindedness’ (Schofield and Beek, 2006), ability to understand the impact of behaviour on the feelings and actions of others and to develop positive and supportive relationships with other people (Healthy Care, 2006). In contrast, a child whose early attachment experiences needs went unmet in a prolonged or traumatic way, perhaps through neglect, or parental rejection, or death, will have difficulty trusting that their needs will be met. The strategies developed to try and manage the anxiety, pain and insecurity of separation can lead to social, behavioural or emotional difficulties, which will impact on the ability to form healthy and trusting relationships, both in childhood and in later life (Healthy Care, 2006; Schofield and Beek, 2006).

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Repeated experiences of loss and separation can make it difficult for children and young people to trust that this will not happen again, and to develop positive relationships with their carers. Every child who is in care has suffered the loss of their family and of course this affects them deeply. Added to that is multiple placements where the children believe they are going to stay for good (in the care of long term fostering) and then the placement breaks down. My son finds it very hard to really believe he is going to stay with us – he has been to so many families and so is not prepared to invest in us. (Foster carer) Respondents discussed the impact these losses could have on children and young people’s behaviour: The children will test your reliability and consistency to ensure that they are safe and are not going to have another loss. (Foster carer) The children have shown signs of an anxious attachment in that they have become very clingy and if there is any change in routine they fall apart until they are helped to feel safe. (Foster carer) The resilience of young people in care can sometimes be overstated and I feel that young people who come to us have all suffered major loss in one or more areas of their lives. It is an area that requires consideration as assumptions can be made about how young people in care can or cannot cope. The impact permeates every area of their lives and is not easily measured in impact upon behaviour as there is such variation on a daily basis. Such conclusions could only be drawn after a more detailed assessment of individual circumstances. (Residential worker) Anxiety about whether a surviving relative will die too is well documented among bereaved children (Dyregrov, 1991) and Worden found that these worries increased significantly during the first year after the death of a parent. These concerns for family members may be more difficult to reassure when children and young people are separated from their families. These concerns can relate to children’s anxieties about themselves: they will need to know that they will be adequately cared for following a bereavement. Children and young people who have come into care as a direct result of bereavement are likely to have experienced great anxiety about what will happen to them and who will look after them. The adults around them may also have been unsure about how care arrangements would be resolved, and this uncertainty may be ongoing. Any child or young person coming into care may have had these fears of abandonment, especially following experiences of neglect, and may be reminded of them if they experience a bereavement while in placement, or if their placement breaks down.

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I feel that the impact of bereavement often brings back those feelings that the child/young person had when they first separated from their families. (Looked after children’s nurse) A child may internalise the loss of their attachment figure as being in some sense ‘their fault’ and display feelings of low self-worth, self-blame, isolation and angry rejection (Howe,1995, p. 131). The self-harming behaviour of some children can be seen as symptomatic of such feelings, as can be their ‘acting out’ and projection of anger and rejection on to substitute carers who, viewed objectively, have never left them or let them down and who are trying to be kind to them. For carers who are unprepared, it can be difficult to cope with these behaviours. The losses [my son] has experienced have led to challenging behaviour and it is difficult to care for someone with such intense needs. (Foster carer) Loss of a parent however negative they may have been has a major impact upon a young person’s relationship with other adults who are caring for them. They often believe that all adults they care about will leave them or die and they will often attempt to destroy these relationships before this happens. Therefore they often move from place to place not forming attachments. (Local authority secure children’s home staff member) Experience of loss is often linked to perceived difficult behaviours i.e. soiling, wetting, eating disorders, self-harm, aggression etc. which put a strain on placements and educational establishments if the reason for such behaviour is not understood. (Looked after children’s nurse) Bereavement has an impact on a child or young person’s behaviour. They can often display their anger (a normal reaction to bereavement) towards their carers and unless carers are prepared and trained in the management of such behaviour, I have seen previously stable placements break down. I have found that in residential care this behaviour then impacts on the other residents and can cause major disruption to the unit. (Looked after children’s nurse) The impact of prior losses can affect friendships as well as relationships with carers. Young people at Aldine House identified that having someone you can turn to for a private chat, a hug and to whom private thoughts and feelings can be disclosed was helpful in dealing with bereavements. Almost 40 per cent of the young people consulted by Jigsaw4u mentioned having friends and being with other people as a key coping mechanism, yet nearly half of them reported difficulties trusting others or making friends. Stable, supportive placements can help children and young people to overcome the difficulties caused by disrupted early attachment experiences and repeated experiences of loss. (Healthy Care, 2006) We did everything we could, seeking lots of help to reassure this placement was not put at risk or made unstable. The impact on the child’s behaviour was

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extreme but under the circumstances we made more allowances to the placement to allow this child to grieve. (Foster carer) [Losses can impact on placement stability] initially, but through time these issues can be resolved â&#x20AC;&#x201C; organised contacts, regular and constructive can help stabilise placement. (Healthy Care partnership) [To support children with losses] we offer support on a daily basis, continue to maintain a dialogue in order to rekindle relationships in the future. Accessed help via social services and have found that perseverance is rewarded. (Residential worker) Everyone works through their loss differently and they should be given the time and space to enable them to come to terms with this. We do feel that they should be given all the time and respect that an adult would be given over the same period. (Foster carer) These strategies for helping children and young people through their experiences of separation and loss echo themes highlighted by Worden (1996) in his discussion of the specific needs of bereaved children. The support which children and young people in public care receive to deal with their other losses can mediate their experience of bereavement and the availability of support to them following the death of someone close to them.

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ÂŠ National Childrenâ&#x20AC;&#x2122;s Bureau 2007

Grief matters for children: Support for children in public care experiencing bereavement and loss

Support for carers The previous section looked at the ways in which carers meet the needs of bereaved children and young people. As many respondents identified, this is difficult and sensitive work, and those providing day-to-day care will need support themselves, as well as access to specialist services to complement the care they provide. Foster carers and residential workers were asked about the help they had accessed in supporting children and young people. This included support from colleagues, CAMHS, specialist bereavement services, teachers or the school, looked after children’s nurse, GP, helplines and websites, books, other resources and other help. Of the 22 foster carers and residential staff in non-secure settings with recent experience of caring for a bereaved child, 14 specified that they had received or accessed help. Of these 14, six identified further help that they would have liked. Five identified that they had received no help, and all of them would have liked to access this. Healthy Care partnerships, looked after children’s nurses, independent fostering providers and local authority secure children’s homes were asked whether they felt that the bereavement support needs of children in public care were met in their area. Fourteen per cent respondents felt that these needs were fully met, 72 per cent felt that they were partly met, and 12 per cent felt that they weren’t met at all.

Training Training foster carers, residential workers and social workers was identified as a key way of providing bereavement support to children and young people. Training should be available for carers. Nothing prepared us for helping the children through this … Bereavement can happen to anyone at any time and carers should be better equipped to deal with this. (Foster carer) This could increase carers’ and social workers’ knowledge about the range of feelings and behaviours which grieving children and young people can demonstrate, helping them to manage their own expectations about appropriate ways of grieving and to understand and cope with the children’s behaviour. Foster carers would benefit from further training and support to handle and understand these behaviours. (Looked after children’s nurse) I researched the effects and cycles of grief. I have found literature that was suitable for the child’s understanding and talked to them about their feelings and how they may find it easier to deal with them. Emotional literacy has been important in this work and the children have benefited from this experience. (Foster carer)

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Forty-one per cent independent fostering providers, Healthy Care partnerships and looked after children’s nurses indicated that they provided or bought in this training. Sometimes this was part of a wider package of training on separation and loss. We try to provide training and support to foster carers and encourage foster carers to attend specific training relevant to their needs. (Independent fostering provider) Training offered to carers is more linked to separation and loss and attachment and includes bereavement as one element of this. (Independent fostering provider) One area was providing training tailored to local needs following the recent suicides of several young people. Training in bereavement within the context of suicide is currently being delivered in the form of a two day course and is targeted across all agencies. (Looked after children’s nurse) Two of the local authority secure children’s homes reported that staff were currently being trained on emotional health and well-being and that the course contained a component on managing bereavement and loss. Of respondents who felt that bereavement support needs in their area were partly met or not met at all, or who felt they wanted more help in this area, 63 per cent felt that more training would be beneficial. Some suggested that this could be multiagency training, and it was suggested that it should include both training in understanding bereavement, and how to access support. Realistic funding was needed to provide this training. Training is not ‘rolled out’ to all workers. (Healthy Care partnership) [I would like to see] much more specialist training being available and provided. Access to trainers experienced and skilled in this area. Finance prevents us from being able to provide this. (Independent fostering provider) Respondents felt that training could be supported by specialist services and through the input of children and young people themselves: This subject could always benefit from more focus through training and education and listening to the experiences of children and young people themselves – i.e. learning from them and using that to inform or develop services. (Independent fostering provider)

What should this training include? Fifteen members of staff of mixed gender and age at Aldine House secure children’s home took part in a survey to help plan a training course to meet their needs in supporting bereaved young people. The majority felt knowledgeable about the needs of bereaved young people and the losses that they have encountered. www.ncb.org.uk

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However, they did not feel confident in offering support to these young people, and felt that training in this was a necessity and should be available to all staff. In addition, very few felt they were sufficiently aware of their own needs to be able to offer the best support to the young people without training. They said that a training course should involve: •

developing an awareness of young people’s feelings and needs

•

touching on staff members’ personal awareness and needs

•

unpacking the skills of working with individuals and groups around bereavement topics

•

developing shared concepts and language

•

jointly developing shared guidelines and best practice

•

increasing staff confidence in areas of bereavement and loss.

Staff in the unit are currently developing this training with the help of the local Gone Forever Bereavement Trust.

What is the impact of training? Jigsaw4u used findings from the consultations they ran with children and young people and their carers to inform the development and piloting of a training day for foster carers. The day was organised through the foster care support team in a London borough and advertised to foster carers registered with the local authority. Fourteen carers signed up for the training, and nine attended on the day. Six of these carers were currently caring for a bereaved child, or had recent experience of this. Drawing on carers’ own experiences as well as those of the children they had supported, the day began with an exploration of the impact which change and loss have on feelings. This was followed by a discussion of research and statistics on the longer term impact of bereavement on children’s lives when it is not addressed. The relevance of these findings for the other losses in children’s lives was considered. A video on the impact of the death of a parent on the life of children and young people was watched and discussed. Carers then discussed a series of case studies of children and young people, looking at the impact of loss and trauma on their feelings and behaviour. This helped them to think about the relationship between the behaviour they noticed among the children in their care, and the children’s past history. The afternoon session looked at practical ways of offering support to children following bereavement and other significant losses. These included making memory boxes and salt jars (containing different coloured sands representing particular memories) and releasing balloons. While making their own salt jar, carers raised questions such as how to find time to talk to children about their experiences, and where to go for further support. www.ncb.org.uk

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After the training, all the carers felt more confident in supporting bereaved children and young people, and more aware of their own needs in doing so. Carers reported that they had learned that grief can last for years and that to help young people, they need to ask what would help, to listen and to provide opportunities to talk. They were particularly pleased to get practical strategies which they could take home and use (‘not just theory’) and ideas about where to go for further help as they had previously struggled to find this. One was ‘feeling empowered and able to help young people address their losses’. The trainer’s suggestions for development included: •

running a repeat session in the evening for foster carers who work during the day

•

running an additional session for social workers and managers to improve their understanding of the issue and support for foster carers, or training both together to help the development of a team around the child.

Supervision, support and information While foster carers and residential workers meet the day-to-day bereavement support needs of children and young people who are looked after, they are part of a wider team around the child including social workers and looked after children’s nurses. Thirteen of the 22 foster carers and residential staff in non-secure settings with recent experience of caring for a bereaved child identified how social workers or looked after children’s nurses had helped by providing information, direct support to the children and young people and by making referrals. In addition, respondents identified the importance of ongoing support and supervision for carers. Foster carers advise that the training they receive could be extended and everyone should attend. They need top-up sessions and a support line. It would help if this was multi-agency training. (Looked after children’s nurse) Family placement social worker has been good to talk things over with for our benefit. (Foster carer) I would like the government and social services to … invest in the foster family to ensure they receive all the help they need and not to forget about this once the child is placed. (Foster carer) Seventy-three per cent of independent fostering providers, Healthy Care partnerships and looked after children’s nurse respondents identified that supervision and support for foster carers was one of the ways the support needs of bereaved children and their carers were met locally. A number of respondents who felt that more help was needed in their area mentioned support for carers, including a support group or support network.

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Carers may need support in dealing with bereavements that affect them directly. Fourteen of the local authority secure children’s homes identified systems, structures and resources which were in place to meet staff needs following the death of a young person or colleague. This included clinical supervision, support from colleagues, occupational health services and referrals to external counselling organisations. A foster carer reported the importance of taking up opportunities available for support: I supported a child two years ago through a tragic loss where I had grown very close to the deceased through supporting the child. The months afterwards were very traumatic for the child and I supported him to the best of my ability but I did not realise how badly I had been affected … I realised afterwards that I needed to be more honest in supervision in order to avoid getting low again. (Foster carer)

Books, helplines and other resources Several foster carers and residential workers mentioned that they had used helplines and websites as a source of support for the children and young people in their care. These included the Winston’s Wish website. Some had also used books, leaflets and other resources given by police or social workers to inform themselves and to support the child or young person. The police handed over [a] booklet, also the local authority provided info. Web was great whilst waiting for these to arrive: downloading info and pictures to colour. (Foster carer) A number of respondents felt that they would like more videos, books or resources to use directly with the child or young person.

The wider social system Seven of the 22 foster carers and residential staff in non-secure settings with recent experience of caring for a bereaved child said that they had received support from school. One foster carer explained (s)he rang school to tell them that when [foster son] came home we had to tell him his Dad was dead and they offered support immediately. (Foster carer) Another carer identified that school had been supportive in acknowledging children’s individual needs. One foster carer explained the help that had been offered by the local funeral director, and two carers discussed how local priests had provided support, one by ensuring the young person’s wishes were carried out at a funeral and one by providing culturally appropriate information about death and bereavement. Other respondents mentioned the police as a source of information and resources.

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Specialist support Specialist support complements the day-to-day support offered by carers and meets particular needs following bereavement, such as addressing trauma or meeting other young people who are bereaved. The majority of young people consulted by Jigsaw4u wanted professionals to work with them to help them solve at least some of the problems associated with their losses. Approximately 20 per cent had received such help, for example access to specialist grief support or counselling services. Of questionnaire respondents who felt that bereavement support needs of looked after children and young people in their area were partly met or not met at all, or who felt they wanted more help in this area, 30 per cent specified that they would like to see more specialist support, either for carers or directly offered to children and young people as one-to-one or groupwork. All of the looked after children’s nurses and Healthy Care partnerships identified that specialist bereavement support for children and young people in public care was available in their area, through therapeutic support teams, CAMHS, school counsellors or referral arrangements with voluntary sector services. Eight of the nine respondents felt that provision for meeting bereavement support was only partly met in their area, and four wanted to see an expansion of specialist services. Thirteen of the 15 secure children’s homes felt that bereavement support needs were not fully met in their unit, and five specified that they would like to access more specialist support. Sixty-eight per cent of the independent fostering providers provided therapeutic or supportive one-to-one work either in-house or through referrals to local services, and 36 per cent provided or accessed group work. Six of the 28 providers wanted more specialist input for bereaved children and young people: one specifically mentioned the need for funding for this work. Respondents identified that there was sometimes confusion about how to access specialist services for children and young people, particularly if court processes were ongoing. Reports from carers are that often social workers delay referral due to court processes. Many carers are unaware that they can receive support by selfreferral. (Looked after children’s nurse) In a recent case, carers advised me that the placement broke down as the children had experienced a parent’s suicide and no support/counselling could be obtained until after the final court hearing. This left the children and carers dealing with significant distress, the direct effect of which was that one child had to move placement. Bereavement support should be available to all children at the time of loss, they should not be disadvantaged by being in the care system. (Looked after children’s nurse)

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One child in my care waited eight months for a referral to a mental health practitioner only to find on the first meeting that the child was already on the file and could have had an instant referral. (Foster carer) Sometimes birth parents do not want to give permission for their children in foster care to have bereavement counselling. (Independent fostering provider) Even if sources of specialist help were available and accessible, they might not be seen as helpful by young people: Official sources [of help] were available but the children are not always so keen on going to them for appointments. (Foster carer)

Child and adolescent mental health services (CAMHS) Thirty-three per cent of questionnaire respondents (not including bereavement care providers) mentioned CAMHS in their discussions of services available locally to bereaved children and young people. Provision at various tiers included one-to-one support for children and young people, supervision of staff and consultation: [Other support is available] with CAMHS team re: concerns over young people and best ways of working etc. (Local authority secure children’s home member of staff) We accessed CAMHS through the child’s social worker…[the help] was excellent. (Residential worker) CAMHS services dedicated to looked after children were mentioned by several respondents, and another felt that this would be useful provision. However, respondents did identify problems relating to underfunding and long waiting lists: We do have access to CAMHS and Tier 2 provision but there are waiting lists and often the placement could break down while the child is waiting for support. (Looked after children’s nurse) Some respondents were uncertain that CAMHS was the appropriate service to meet general bereavement support needs, given its wider remit on mental health and the general high threshold of concern for referral. In line with NICE and DOH guidelines specialist CAMHS does not identify bereavement per se as a mental illness. (Healthy Care partnership)

Specialist childhood bereavemen t services Thirty-one per cent of questionnaire respondents (not including bereavement care providers) identified voluntary sector specialist childhood bereavement services in their area, which they had accessed or were aware of, including stand-alone services and those based in hospices.

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Many such services offer a range of provision to children bereaved in particular circumstances: some attached to hospices which support those whose parent, carer or sibling has died in the hospice’s care. Over 70 ‘open access’ childhood bereavement organisations in the UK offer a range of services to bereaved children and young people in a particular catchment area, whatever the cause of death of the person who has died. This community based model aims to provide flexible, non-stigmatising support which acknowledges the bereaved child as grieving, not ill (Willis, 2005). A 2003 survey showed that 85 per cent of childhood bereavement services are located in the voluntary sector (Rolls and Payne, 2003). Six of the seven bereavement care providers who responded to our questionnaire indicated that they were currently working with bereaved children and young people who were fostered, and four were working with bereaved children and young people in residential care. The range of provision included: Open access service offered. Direct one-to-one support with the child, family support, consultancy service for professionals, parents and carers. (Bereavement care provider) One-to-one work, group work and work with school and foster carers. Referrals come from SS [social services], direct from foster carers, school and from health services. (Bereavement care provider) An independent fostering provider indicated how group activities could help bereaved looked after children: Bereavement is an isolating experience – they would benefit from mixing with other bereaved children. (Independent fostering provider) Many childhood bereavement services offer these opportunities through social events, access to networks of similarly bereaved families, weekend events or residential camps, memorial events and closed or open group sessions (Willis, 2005). However, a bereavement care provider indicated that there were implications for looked after children accessing these services: Sometimes the foster carers join the carers’ group, but as they haven’t been bereaved it’s usually appropriate for then to sit and wait – this makes their experience and that of the children and young people attending the group different from the others [who are attending as a birth family]. (Bereavement care provider) Additionally, foster carers didn’t always receive information from social work teams about local sources of specialist help. I have had to find my own resources as none were available through social services … I have contacted the local hospice in order to support a child … if I had not used my own initiative then there would have been little if any help available when the child needed it. (Foster carer)

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Grief matters for children: Support for children in public care experiencing bereavement and loss

Several bereavement care providers discussed the services they offered to foster families and residential settings caring for children who were dying. Key issues raised included meeting the different needs of both grieving foster families and grieving birth families, and negotiating parental consent and young people’s own plans for their death. [We] have a Community team who offer support to parents and carers, life limited children and young people and the children in the family who are also involved with the ill child or young person. We offer psychosocial/bereavement support from the onset. (Bereavement care provider) Bereavement care providers were asked how they deal with referrals that related to losses other than bereavement. Some offered services to bereaved children only and would refer on where appropriate: [We get asked to help with other losses of] divorce and separation. If there is a bereavement issue, we can include these other issues. If no bereavement, [we] refer on to another agency. (Bereavement care provider) while others, particularly those working with young people with a life-limiting condition, would offer support around separation from the family and other losses, depending on their identified referral criteria.

Planning One foster carer identified how a coordinated approach, underpinned by good planning and using the team around a child, had worked well to complement specialist support: As the work carried out in therapy is confidential and not shared with the carer it does not offer sufficient support for a planned approach by all involved. I am very much in favour of the new approach where a network (including SW [social worker], CAMHS, school and carer) decide a plan and approach for helping the child. The co-ordinated approach offers a greater opportunity to make positive progress. This does not necessarily replace individual therapy. (Foster carer)

Care plans Care plans are prepared for all looked after children, setting out the child’s needs and how the local authority will meet them, and detailing where they will live, arrangements for contact with their birth family and other important information about their lives. The care plan should be updated at regular review meetings. The majority of Healthy Care partnership staff, Looked after children’s nurses and residential workers indicated that the impact of bereavement was included in care plans. Respondents indicated that the care plan could be used both to identify practical issues such as anniversary commemorations, going to the funeral and making staff aware of significant dates, as well as a chance to plan for work on the www.ncb.org.uk

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emotional impact of bereavement and loss, either using an external agency or through internal staff expertise. From recall of a situation a number of years ago (in a different home) a child recently placed lost his mother ... planning did involve bereavement counselling and re-establishing link with extended family. (Residential worker) If a bereavement occurs during a placement, the care plan is likely to need updating ‘in areas such as contact and possible future plans.’ (Residential worker). However, the plan was felt to be only as good as the information in it, and while specific work could be included if the bereavement was known about or had occurred while the child was in care, information about significant bereavements was often missing.

Health plans The health plan forms part of the care plan, and looks in detail at the child’s health needs. All but one Healthy Care partnership and looked after children’s nurse indicated that bereavement support needs were included in the health plan in their area, or that this was under development. A looked after children’s nurse wanted to see Screening assessments for children coming into care to establish levels of support for carers. (Looked after children’s nurse) This could identify support needs and possible traumatic stress reactions among children and young people entering care.

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Unaccompanied asylum seeking young people Many of the points raised already in this report will be relevant to refugee and asylum seeking young people in public care, of which there were 3,200 on 31 March 2006 (DfES 2006b). However, these children and young people face additional and particular issues that can mediate their experience of bereavement and the support available to them and their carers.

Traumatic experiences A number of our questionnaire respondents raised that these young people are particularly likely to have experienced traumatic bereavements, and this was supported by the consultations that Jigsaw4u carried out with 31 unaccompanied asylum seeking young people. Forty-two per cent knew or believed that one or both of their parents had been killed, and 10 per cent knew or believed that siblings had been killed. These children and young people had experienced other traumatic and lifethreatening events while in their country of origin and during their journey. Each young person had experienced an average of four traumatic events in their lives. Ninety-seven per cent were forced to leave their home, 81 per cent had been exposed to wartime violence, 68 per cent had been imprisoned and 42 per cent had been tortured. Almost half had been forced to flee because they had been forcibly separated from their parents, or their parents had been killed (48 per cent). Persecution (32 per cent), war (26 per cent) and parents being imprisoned (13 per cent) made up the other main reasons for seeking refuge. As most of these young people did not enter the UK by formal asylum/refugee seeking avenues, their traumatic experiences continued on their journeys to the UK. Three female participants in the consultation reported that they had been raped during their journey. The majority reported long journeys lasting days or even weeks, often with no knowledge of their destination, little food and drink, and fear of arrest while in transit. On arrival in the UK, many were abandoned by the person who helped them get here, and spent their first night on the streets or in other dangerous places. Some reported further traumatic experiences while in the UK, including racial assault and burglary. Many had to come to term with the news of the death of close relatives they had left behind. Traumatic and life-threatening experiences can lead to a variety of stress responses (Yule, 2005), which may be seen as a ‘natural response to extraordinary circumstances’ but which can nevertheless have a major impact on children and young people’s health and functioning. It is widely held that grief may be inhibited by these stress reactions which can persist for many years and which may need to be treated first (Yule, 2005). www.ncb.org.uk

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Dealing with the here and now In addition to the traumatic experiences they may have had, unaccompanied asylum seeking children and young people face a range of new challenges on arriving in the UK and attempting to settle among new social and cultural experiences. They may experience great anxiety about what will happen to them and how they will be cared for. Young people in supported lodging schemes have to acquire life skills quickly, without the encouragement and support they could have received from their family and community. Those in foster care have to adapt to the routines of a new family. These tasks can take precedence over thinking about the past: The practicalities of daily living are the ones that they attend to first and once that is done they focus on the future and possible family reunification for example, as well as immigration status, and then once all those things are in place they are able to look back at their past, so the normal pattern of resettlement is present first, the future next and the past last. (Kohli, 2005) Language can be a barrier to accessing learning and support and in the absence of specialised and targeted support to bring young people up to speed, many struggle to realise the full benefits of schooling. While young people reported having friends and being with other people as a key coping mechanism, the reality of being in a new culture makes many wary of making friends and revealing their ‘true self’ for fear of prejudice and rejection.

Lack of information Worden identified the importance of providing adequate information about a death to bereaved children. This is a particular challenge to those caring for unaccompanied asylum seeking and refugee children, as they are unlikely to be able to provide information about the (frequently traumatic) deaths which they have experienced in their country of origin, or to know about the impact of bereavement on the young people in their care: Q. How has bereavement through death affected the feelings and/or behaviour of the children in your care? A. This was a young person who had come into the country as a minor, so unsure of exact experiences. (Foster carer) A lack of information about relatives still in the country of origin can leave children and young people with tremendous anxiety. Most young people consulted by Jigsaw4u were worried about those they had left behind, often with no knowledge of their whereabouts, including one young mother who had had to leave her baby. Some had contacted the Red Cross for help in locating relatives but success was patchy and even once contact has been established, it is expensive to maintain.

Cultural understandings of death and bereavement Carers pointed out that differing cultural practices around death and bereavement meant that some of the ways they might have offered support to a bereaved young

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person in their care were not appropriate when working with asylum seeking and refugee children. There are of course huge variations in cultural interpretations of death and bereavement, and carers need information and guidance in finding ways of responding individual needs. [The school] got a Catholic priest, who has worked…with African children to come and talk to [our son] and to acquaint us with…‘customs’ etc surrounding death [in his country]. (Foster carer) Culturally, people from [our son’s] background do not mark birthdays or anniversaries. We have informally given lots of space to talk about childhood memories, cultural practice, family etc. (Foster carer)

Accessing specialist services Children and young people from cultures with different understandings of mental health, which may not recognise Western notions of counselling or support, may be reluctant to access specialist bereavement support. This can make a referral an unhelpful or meaningless exercise (Lynch, 2000). Local specialist services may need additional information and development to extend their services to meet the differing needs of asylum seeking children and young people. In any case, specialist services may not be available or accessible, and even when they are, children and young people may not be ready to access them. The young person was given access to a counsellor trained in the specific needs of refugees and asylum seekers and used to working with unaccompanied minors. He only went once and then refused to make further use of the service … the help offered was very good, but the young person was just not ready or able to make use of it. (Foster carer)

Support for carers The complex needs of these young people and the issues in providing bereavement support present challenges to the carers responsible for meeting their day-to-day emotional needs. Carers identified that they needed more help in providing this level of care: We would have benefited from more opportunities to debrief with the child’s social worker or our link worker. In particular at the outset of placement, it was quite intense for all concerned and the young person was not ready to accept outside help so we were the only source of support. (Foster carer) With the unaccompanied minors, very little specific training was given [to us] though many (if not most) of these children are bereaved through extreme circumstances. (Foster carer) Further work is recommended to explore the pressing specific support needs of bereaved asylum seeking and refugee children and those caring for them on a dayto-day basis. www.ncb.org.uk

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Children and young people in secure accommodation Children and young people whose placements are in local authority secure children’s homes will face many of the issues already discussed in dealing with bereavement. However, the setting in which they live can bring additional challenges which affect their experience and their ability to access support. On 31 March 2006, 300 children and young people in England were accommodated in secure children’s homes (DfES, 2006a). Guidelines on bereavement and loss produced by staff at the Atkinson Unit secure children’s home point out that, 'Our unit sustains children who have all had to deal with significant loss – the loss of freedom' (Atkinson Unit, 2005, p. 2) and gives examples of the losses which this group may face as including: When a child loses someone who is close to them; when a friend or member of staff dies or leaves suddenly; following serious incidents, which may relate to previous or current loss; during periods of great change or unrest. (Atkinson Unit, 2005, p. 2) Young people consulted at Aldine House secure children’s centre felt that all young people’s experiences of loss mattered. However, they said that the secure setting brought extra dimensions of loss into their lives, which included: •

loss of liberty and freedom

•

relationships (boyfriend/girlfriend/pets/friends and family, emotionally, sexually or intimately)

•

privacy (particularly conversation between themselves)

•

choice (not seeing family and friends when they want, not being able to eat when they want or sometimes what they want)

•

interaction (within the community)

•

family (not being able to see or be with family every day)

•

normality (can’t do what ‘normal’/other young people [not in secure accommodation] can do)

•

social life (having fun, meeting friends)

•

love (intimacy through touch, hugging and kissing).

They described the ways these losses made them feel: •

upset – cry

•

think a lot – don’t know what to do with yourself

•

angry, annoyed

•

frightened, scared and nervous

•

empty/sad

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•

lose control of yourself

•

misunderstood

•

devastated

•

threatening/aggressive/violent

•

lonely/left/deserted

•

frustrated/shout/scream

•

guilty

•

dream

•

moody

•

helpless

•

untrusting – find it hard to communicate with others

•

revengeful

•

confused

•

self harm

•

depressed.

Questionnaire respondents working in secure centres echoed these varied additional losses and the impact they had on children and young people’s feelings and behaviour. Family is important to most young people. Being placed in secure accommodation immediately evokes feelings and experiences of separation and loss. (Local authority secure children’s home staff member) All were able to describe strategies they had used to help children and young people acknowledge their grief and loss, for example: Life story work, releasing balloons on anniversary of death with message attached, Muddles and Puddles [book of activities for bereaved children], photographs. (Local authority secure children’s home staff member) Two units felt that the support needs of children and young people affected by bereavement were fully met in their unit, and thirteen felt that they were partly met.

Involvement and inclusion after a death The young people identified that being able to say goodbye to the person who has died could help. The significance of being involved after a death, and particularly in being given a choice about going to the funeral has already been discussed. Secure settings may mean additional barriers to young people’s involvement with the rest of their grieving family. One young person described his frustration following the death of a member of his family: I find it hard to cope being locked up and not being there to support my mum: his death has come as a great shock to us all. (Young person) www.ncb.org.uk

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A lack of suitable accommodation locally means that children and young people are sometimes placed a long way from home, and staffing pressures can mean that attending a funeral is not prioritised. Secure environment restricts grieving process for some young people, for example, not all can attend funeral, cemetery etc. (Local authority secure children’s home staff member) A young woman in a medium secure psychiatric unit said My Gran died five months ago. I was not allowed to go to the funeral even though it meant so much to me to say goodbye … I should have been allowed to go to the funeral. I will never get my chance to say goodbye now, and I am really angry about that. Obviously staff in units like this should make plans for young people like me to be accompanied to funerals, no matter how far from the unit. (Young woman) A composite case study in the Atkinson Unit's guidelines on bereavement and loss identifies how a personal memorial service could be held in the unit if a young person was unable to attend a funeral in the community (Atkinson Unit, 2005).

Boundaries and isolation Young people felt that the expectations on them to cope with bereavement were higher than among children not in a secure setting. They felt that it would be helpful to relax the structure and boundaries of the centre’s environment, and to have ‘grieving time’. They felt that the expectations on them were higher because they felt alone, and said that learning to trust was helpful in dealing with the losses they faced. One young person explained: It’s harder being locked up because you can’t go and have a hug with mum and don’t know who to talk or turn to because you don’t know who to trust. (Young person) Young people identified the need for someone to listen when they are ready and able to talk. All of the secure children’s homes which responded to the questionnaire were providing one to one support, either through a staff member or an external agency, and specialist support was offered by professionals from backgrounds including psychology, psychiatry, art therapy, counselling and chaplaincy. Eleven of the homes specified that the young people had access to helplines. To meet specific needs around bereavement, one unit described how they: Now have an internal bereavement worker at the unit, providing work with young people and training for staff. (Local authority secure children’s home staff member)

Behaviour and placement stability The young people wanted opportunities to release feelings of anger in an appropriate way such as going outside, kicking a ball, screaming: ‘whatever it takes www.ncb.org.uk

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for as long as they need’. As with questionnaire respondents representing other types of placement, staff from secure children’s homes identified that the children and young people’s feelings and behaviour following a bereavement could be difficult for staff to recognise and manage: The young person often feels isolated by the very fact that they are locked in a secure unit away from their families/significant others. Bereavement can increase feelings of isolation. This can at times result in anger and ‘acting out’ behaviour by the young person. If this behaviour is not understood and the appropriate strategies [not] put in place then there is a risk that the situation gets out of control and the placement being terminated and the young person transferred (Local authority secure children’s home staff member) However, others felt that this kind of placement was not as fragile as those in foster care or non-secure settings: There is no option for placements to fail as in community settings. (Local authority secure children’s home staff member) Although not fragile, many placements in these settings were short term, which brought its own challenges: We identify issues that may need therapeutic input. However, frequently this does not begin as children are placed ‘out of county’ and therefore we are told it is not appropriate to begin work that may need to extend beyond sentence. (Local authority secure children’s home staff member)

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Conclusion All children and young people need support and care following the death of someone close to them. This includes children and young people in public care, who may be more likely to have experiences of bereavement, including sudden and traumatic death, who may be isolated from networks of other grieving family members, and who may have experienced varied and repeated losses alongside the death. Experiences and particular support needs will vary from child to child. As shown by Chantelle’s poem, which opened this report, and by the many examples of helpful strategies given by questionnaire respondents, carers can provide supportive, responsive environments that meet these needs. However, the availability of support can be compromised by a lack of information for children, young people and their carers about the circumstances of a death, about grief reactions and about sources of support; by instability in placements; and by the impact of other losses. Additional issues in accessing support are faced by young asylum seekers, and those in secure children’s homes. Carers supporting these children and young people need help themselves in providing appropriate information and support, understanding feelings and managing behaviour associated with bereavement, and supporting young people to overcome the challenges of their early experiences. Yet, carers and children can be left feeling alone in dealing with the aftermath of a significant death: We expect a lot from children and young people. We expect them to deal with a great deal of loss of various kinds and are ‘surprised’ when they can’t. (Foster carer) Nothing prepared us for helping the children through this. (Foster carer) The local authority team around a child and his or her carer must acknowledge the significance of bereavement and loss in the lives of looked after children. Support must be available to the carer in meeting the day-to-day needs of the child which stem from these losses. This support must stretch across the whole care system, from the adequate preparation and training of carers, through careful assessment of needs on arrival into care, through supervision for carers and swift referral to specialist services when necessary, to thorough planning for leaving care. This Healthy Care environment will help looked after children and young people to manage the impact of death on their lives. Our comments would be to ensure that all children despite placement or experience should be given the opportunity to have their bereavement support needs met, through the most appropriate resource that will best suit them. (Bereavement care provider)

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Recommendations All bereaved children and young people in care should receive support that meets their individual needs. To ensure this happens, the following need to be in place:

Policy •

The impact of bereavement and multiple loss on the well-being of children and young people should be acknowledged in the forthcoming Care Matters: Next

steps. •

The impact of bereavement and multiple loss on young asylum seekers and refugees should be included in policy and planning for these young people.

•

Examples of good practice in meeting the support needs of children in public care and their carers should be published in a Healthy Care briefing paper for policy-makers and service managers.

•

The role of voluntary and community services in providing bereavement care and support should be acknowledged in the forthcoming Care Matters: Next

steps. •

Training should be provided for all carers and for the team around a child to understand that needs relating to attachment, loss and bereavement are a priority for this group. This should include awareness of carers’ own needs, understanding of continuing bonds, cultural understandings of death and bereavement, and knowledge of some of the common reactions and simple strategies for support.

•

Data should be collected on the number of children and young people who enter public care as a result of bereavement, to aid policy and planning.

Partnership •

Social services, health and local bereavement services should develop funded partnership arrangements to ensure that specialist input, training support and direct work with children and young people and their carers is available across the country.

•

Palliative care and end-of-life services should have good links with local social services teams to ensure adequate planning for the children around the death of a lone parent.

•

Local authorities should provide support opportunities for carers supporting children and young people through the impact of bereavement.

•

Further work should take place to explore opportunities to bring together bereavement care providers and carers supporting bereaved asylum seeking and refugee children.

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Participation •

Children and young people should be provided with a choice of high quality opportunities to understand the impact of bereavement and loss in their lives, and to express their feelings.

•

Children and young people should be supported in choosing whether to attend the funeral of someone important to them, and in getting there if they choose to go.

•

Children, young people and their carers should be provided with information about bereavement and its impact, and about local and national sources of support and referral routes.

•

Children and young people should be supported to maintain contact with birth family members where appropriate.

Practice •

Subject to confidentiality, carers should be given all the information they need about a child or young person’s history to be able to offer appropriate support.

•

Carers should be given adequate support to ensure the stability of high quality placements. Stability of other relationships is important to children and young people too: measures should be put in place to improve the retention of social workers.

•

Children coming into care should be assessed for any support needs stemming from their experiences of bereavement, and these should be prioritised as part of their health plan. This assessment should include screening for traumatic experiences.

•

Carers should be supported in managing their own experiences of loss and bereavement.

•

Further work should be undertaken to explore issues of bereavement and loss in the lives of children and young people in residential care.

•

Further work should be undertaken to explore issues of bereavement and loss among disabled children in public care.

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References Amato, P (2000) ‘The consequences of divorce for adults and children’, Journal of Marriage and the Family 62, 4, 1269-87, in Ribbens McCarthy, J with Jessop, J (2005) Young People, Bereavement and Loss. Disruptive transitions? London: NCB. Atkinson Unit (2005) Loss and Bereavement Guidelines and Policy. Devon: Atkinson Unit. Bird, J and Gerlach, L (2005) Improving the Emotional Health and Well-being of

Young People in Secure Care. Training for staff in local authority secure children’s homes. London: NCB. Chambers, H (2005) Healthy Care Programme Handbook. London: NCB. Christ, G (2000) Healing Children’s Grief: surviving a parent’s death from cancer. Oxford: Oxford University Press. Cloitre, M and others (1996) ‘Memory performance among women with parental abuse histories: enhanced directed forgetting or directed remembering?’, Journal of Abnormal Psychology 105: 204-211. In Stokes, J A (2004) Then, Now and Always.

Supporting children as they journey through grief: a guide for practitioners. Cheltenham: Winston’s Wish. Cousins, W and others (2003) The Care Careers of Younger Looked after Children: findings from the multiple placements project. Belfast: Queen’s University Belfast. Cross, S (2002) I Can’t Stop Feeling Sad: Calls to Childline about bereavement. London: ChildLine. DfES (2006a) Children Accommodated in Secure Children’s Homes, Year Ending 31 March 2006: England and Wales. Accessed on 16 April 2007 from http://www.dfes.gov.uk/rsgateway/DB/SFR DfES (2006b) First Release: Children looked after in England (including adoptions and care leavers 2005-6). Accessed on 16 April 2007 from http://www.dfes.gov.uk/rsgateway/DB/SFR/s000691/index.shtml DfES (2006c) Statistics of Education: Children looked after in England Year ending 31 March 2005. London: DfES. DfES (2006d) Care Matters: Transforming the lives of children and young people in care. London: DfES. Dent, A (2005) ‘Theoretical perspectives: linking research and practice’ in Monroe, B and Kraus, F (eds) Brief Interventions with Bereaved Children. Oxford: OUP. Dowdney, L (2000) ‘Annotation: Childhood bereavement following parental death’, Journal of Child Psychology and Psychiatry, 7, 819-830. www.ncb.org.uk

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Dyregrov, A (1991) Grief in Children: A handbook for adults. London: Jessica Kingsley Publishers. Fitzpatrick, P (2005/6) ‘How to help children and staff cope with loss’, Youth Justice

Board News Dec/Jan p8 Franzen, E and Vinnerljung, B (2006) ‘Foster children as young adults: Many motherless, fatherless or orphaned: A Swedish national cohort study’, Child and Family Social Work, 11, 254-263’ Gersten, JC and others (1991) ‘Epidemiology and preventive interventions: parental death in childhood as an example’, American Journal of Community Psychiatry 19, 4, 481-98, in Ribbens McCarthy, J with Jessop, J (2005) Young People, Bereavement and Loss. Disruptive transitions? London: NCB. Green, H and others (2004) Mental Health of Children and Adolescents in Great Britain. London: HMSO. Healthy Care (2006) Secure Attachment Promotes Health and Well-being. London: NCB. E-briefing accessed 14 May from http://www.ncb.org.uk/dotpdf/open_access_2/hcb_secure_attachment.pdf Hetherington, EM (2003) ‘Social support and the adjustment of children in divorced and remarried families’, Childhood: A global journal of child research 10, 2, 217-53. in Ribbens McCarthy, J with Jessop, J (2005) Young People, Bereavement and Loss. Disruptive transitions? London: NCB. HM Treasury (2003) Every Child Matters. London: TSO. Holland, J and Randerson, C (2005) Supporting Children in Public Care in Schools. London: Jessica Kingsley Publishers. Holland, J (2001) Understanding Children’s Experiences of Parental Bereavement. London: Jessica Kingsley Publishers. Howarth, G and Leaman, O (eds) (2001) Encyclopedia of Death and Dying. London: Routledge. In Rowling, L (2003) Grief in school communities: effective support strategies. Buckingham: OUP. Howe, D (1995) Attachment Theory for Social Work Practice. London: Macmillan. Klass, D, Silverman, P R, and Nickman, S L (1996) Continuing Bonds: New understandings of grief. Washington DC: Taylor and Francis. Kohli, R (2005) talking about asylum seeking children in Cooke, E (ed) On new

ground: supporting unaccompanied asylum seeking children and young people Audio Series 9 Research into Practice from www.rip.org.uk/publications Lynch, M (2000) ‘Understanding the needs of young asylum seekers’, Archives of disease in childhood 83, 384-387.

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Mack, KY (2001) ‘Childhood family disruption and adult well-being: The differential effects of divorce and parental death’, Death Studies 25, 5 419-43. In Ribbens McCarthy, J with Jessop, J (2005) Young People, Bereavement and Loss. Disruptive transitions? London: NCB. Melvin, D and Lukeman, D (2000) ‘Bereavement: A framework for those working with children’, Clinical Child Psychology and Psychiatry, 5, 4, 521-539. Office of National Statistics (2005) Mid-2005 Population Estimates. London: HMSO. Parkes, C M (2006) Love and Loss: The roots of grief and its complications. Hove: Routledge. Parkes, CM (1998) Bereavement. Harmondsworth: Penguin. In Ribbens McCarthy, J with Jessop, J (2005) Young People, Bereavement and Loss. Disruptive transitions? London: NCB. Rolls, L and Payne, S (2003) ‘Childhood bereavement services: A survey of UK provision’, Palliative Medicine, 17, 5, 423-32. Ribbens McCarthy, J with Jessop, J (2005) Young People, Bereavement and Loss. Disruptive transitions? London: NCB. Schofield, G and Beek, M (2006) Attachment Handbook for Foster Care and Adoption. London: British Association for Adoption and Fostering. Stokes, J A (2004) Then, Now and Always. Supporting children as they journey through grief: A guide for practitioners. Cheltenham: Winston’s Wish. Willis, S (2005) ‘Work with bereaved children’ in Monroe, B and Kraus, F (eds) Brief interventions with Bereaved Children. Oxford: OUP. Worden, J William (1996) Children and Grief: When a parent dies. New York: Guilford Press. Yule, W (2005) ‘Working with traumatically bereaved children’ in Monroe, B and Kraus, F (eds) Brief Interventions with Bereaved Children. Oxford: OUP.

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